Cultural Sensitivity and Awareness in the Delivery of Health Care

ABSTRACT: Communication with patients can be improved and patient care enhanced if health care providers can bridge the divide between the culture of medicine and the beliefs and practices that make up patients' value systems. These may be based on ethnic heritage, nationality of family origin, age, religion, sexual orientation, disability, or socioeconomic status. Every health care encounter provides an opportunity to have a positive effect on patient health. Health care providers can maximize this potential by learning more about patients' cultures.

Obstetrician–gynecologists often come upon cultural issues in all aspects of their care, including the labor suite, office, and during preoperative encounters. Understanding the cultural context of a particular patient's health-related behavior can improve patient communication and care (1). This Committee Opinion contains several clinical vignettes pertinent to the obstetrician–gynecologist, but many other situations can be encountered in daily practice. When an individual's culture is at odds with that of the prevailing medical establishment, the patient's culture generally will prevail, often straining physician–patient relationships. Physicians can minimize such situations by increasing their understanding and awareness of the cultures they serve or by being open minded and educating themselves regarding those that they do not know.

Culture is defined as the dynamic and multidimensional context of many aspects of the life of an individual (2). It includes gender, faith, sexual orientation, profession, tastes, age, socioeconomic status, disability, ethnicity, and race. Cultural competency, or cultural awareness and sensitivity, is defined as, "the knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences, self awareness, knowledge of a patient's culture, and adaptation of skills" (3).

Many cultural groups, including gay and lesbian individuals; individuals with disabilities; individuals with faiths unfamiliar to a practitioner; lower socioeconomic groups; ethnic minorities, such as African Americans and Hispanics; and immigrant groups receive no medical care or are grossly underserved for multiple reasons. Lack of cultural competence of health care providers is one of the reasons these groups receive inadequate medical care.

Changing Demographics

For centuries, the United States has incorporated diverse immigrant and cultural groups and continues to attract people from around the globe. From 2000 to 2009, there was a 32% increase in the Asian population, a 37% increase in individuals of Hispanic origin, an 18% increase in American Indians and Alaskan Natives, and a 13% increase in the African American population. The white non-Hispanic population increased by only 2%. In 2009, non-Hispanic whites represented 65.1%, Hispanics (of any race) represented 15.8%; African Americans represented 13.6%; Asians represented 4.6%; and American Indians, Alaskan Natives, Native Hawaiians, and other Pacific Islanders represented 1.2% of the total 307 million inhabitants of the United States (4). Currently, however, minorities outnumber whites in some communities in the United States.

Selected Examples in Clinical Practice

The cases in Table 1 are intended to highlight the importance of cultural sensitivity in clinical practice. Although these examples represent dramatic situations, the traditional approach can fail to gather the most crucial information for providing appropriate medical care. These examples are clearly not all encompassing, but can serve as useful teaching tools for those in practice as well as medical students and ob-gyn residents who may not be aware of these issues.

Table 1. Cultural Sensitivity in Practice

Original Scenario—Insurance

Culturally Sensitive Approach

An Amish woman undergoes a cesarean delivery. After surgery, the woman and her husband are interviewed by a social worker who was called by a nurse to see the couple because they had no health insurance. The social worker immediately begins to tell them how to enroll in Medicaid. They are visibly upset and will no longer talk to the social worker. They refuse to complete any paperwork for Medicaid. They ask to leave the hospital as soon as possible

The social worker is called by a nurse because the couple does not have health insurance. The social worker is aware that this is an Amish couple and knows that generally Amish people do not believe in or accept what they consider to be welfare. When the social worker meets with the couple, she confirms that they are not seeking assistance in acquiring health insurance; she helps them plan transportation home, and she assists them in reaching other members of their Amish community who, by tradition, provide financial and other assistance to their own people.

Original Scenario—Respect*

Culturally Sensitive Approach

A 30-year-old physician enters the examination room to see his next patient who is a 50-year-old African American woman; he introduces himself, addresses her by her first name, and asks why she has come to the office today. The patient becomes visually upset and gets up to leave. She tells the office staff as she leaves that she will never return to that doctor.

The clinician is aware that addressing patients by their first names may be perceived as disrespectful, especially for certain minority groups. Every patient can be asked an open-ended question about how she would like to be addressed (Miss, Ms., Mrs., Dr., Professor) by the health care provider. The name by which she wishes to be addressed may vary by many factors, including whether the patient resides in a rural or urban setting, whether she knows the health care provider or is a stranger, and what her age is. The patient in this example should be addressed by all members of the health care team by her preferred mode of address. This preference can be noted in the medical record to remind everyone how she wishes to be addressed.

Original Scenario—Informed Consent and Medical Decision Making*

Culturally Sensitive Approach

A 17-year-old Hispanic woman has an arrest of labor for several hours and it is decided that a cesarean delivery needs to be performed. Labor and delivery is extremely busy, and a nurse brings in the standard surgical consent form, hands the patient a pen, and insists that the patient sign it. She and her family are clearly uncomfortable.

The nurse realizes that there are many members of the family crowded in the patient's room and also understands that for many women of Hispanic heritage, it is customary to involve family members in medical and personal decisions. The nurse and resident caring for the patient explain to the entire family the reason that a cesarean delivery is needed and the family understands. The patient is then asked to sign the surgical consent form.

Original Scenario—Concerns Over Medical Tests*

Culturally Sensitive Approach

An elderly Chinese woman is asked by her physician to go to the laboratory to have blood drawn for tests. She takes the laboratory slip but does not get the tests, nor does she return to see that physician.

The primary care physician orders laboratory tests on his patient, but notes the woman's hesitation and asks her why she is worried. She tells the physician that she believes that blood taken from her body will never be replenished and she is weak already. The physician spends time explaining how blood is replaced and the importance of the tests. The patient has the blood tests as the physician requested.

Original Scenario—Sexual Orientation*

Culturally Sensitive Approach

A lesbian sees a gynecologist for the first time. The patient has marked “sexually active” and “not married” on the intake form, and the physician asks what type of birth control she is using. The patient shrugs, and the physician spends several minutes discussing available options. She is sensitive to her needs but keeps insisting that she consider using birth control. As the woman leaves the office, she is upset and refuses to see this gynecologist again.

The physician uses intake forms that do not assume heterosexuality. The form asks if the patient is sexually active and then asks with men, women, or both. The form asks if the patient is single or has a partner. The physician takes her time in asking about the patient's sexual history, and takes time to assure confidentiality because many patients will not disclose sexual behaviors, especially on forms that can be viewed by the entire office staff. The physician then learns that the patient is in a lesbian, long-term, committed relationship, and currently has no need for birth control.

Original Scenario—Interpretive Services*

Culturally Sensitive Approach

A couple has newly arrived in the United States from Afghanistan. The wife is uncomfortable. They do not speak English well, so an interpreter is found. The interpreter appears to be having difficulty interpreting the woman's symptoms; the history that is obtained is nonspecific. The physician cannot find any abnormalities on physical examination and discharges the patient home. Later, she returns with a ruptured ectopic pregnancy and is immediately admitted to the operating room.

The physician notices that the interpreter is not able to communicate well with the couple. He asks the interpreter why the history is so difficult to obtain. It takes a few moments to discover that the couple speaks Dari and the interpreter speaks Pashto. The physician seeks an appropriate interpreter and finds the patient has mild pelvic pain and vaginal bleeding; a pelvic ultrasound reveals an unruptured ectopic pregnancy that is treated appropriately.

Original Scenario—Social Context*

Culturally Sensitive Approach

A young white woman has recently moved to the city from a rural area. She is 4 months pregnant and has four children, whom she brings with her to her prenatal visits. She is always an hour late for her appointments and the office policy is that she must wait until everyone else is seen before she is seen. She refuses to fill out her medical history forms and states that she requested her previous records to be transferred. Her children are impatient in the waiting room. The office staff members complain about this situation and make disparaging comments on days when she is scheduled for a visit.

When the patient is an hour late for her first appointment, a staff member takes some time to inquire about why she is so late. She explains that she is new to the city, has no reliable transportation, and she has to take two buses to get to the clinic. She explains her living situation and that she has no one to watch her children. She also reveals that she is unable to read. A peer counselor arranges for help with learning the bus route and planning her trips. She also is referred to a literacy program for help. One of her first triumphs is learning to recognize the signs on the buses. Over the course of her pregnancy, she learns to read the bus route map and schedule.

Original Scenario—Birth Rituals

Culturally Sensitive Approach

A Chinese couple experiences the birth of their first child. The nurse on the postpartum floor is alarmed to find the room very hot and the couple refuses to have the baby bathed. The mother refuses to eat any hospital food or bathe. In addition, the nurse complains to the physician that the body odor is overwhelming in the patient's room.

The physician ensures that all personnel involved during the birthand postpartum time understand that many Chinese people believe that cold liquids and baths will harm the mother and baby. Special foods are believed to be of paramount importance for the proper cultural initiation of the baby and mother.

Original Scenario—Faith

Culturally Sensitive Approach

A Latina presents for the fifth time to labor and delivery for hyperemesis gravidarum. Her English is limited. She is 14 weeks pregnant and through an ad hoc interpreter (her son) reports that she cannot stop vomiting and that the medicines are not working. The patient is admitted for routine hyperemesis treatment and vomits little. She is discharged home after 24 hours only to return again the next day with the same symptoms. The residents and staff members are frustrated and label her as a “frequent flyer.”

The staff member and resident obtain the assistance of a certified interpreter to interview the patient on her fifth admission to the hospital. During this interview, the staff member asks if there is anything happening at home that might be contributing to her illness, such as lack of food, inability to purchase the nausea medicines, or lack of social support. The staff member also asks what the patient thinks is making her ill. The patient then relates that her neighbor has told the patient she has cursed her and her pregnancy. This is why the patient says she is vomiting. She says she gets better in the hospital because she is away from the neighbor. When asked if there is anything she believes can be done, the patient states that a Spiritual Healer could lift the curse. After such a healer is located in a nearby community and performs the ritual, the patient's vomiting ceases

Suggestions for Coping With Cultural Issues in the Office

As can be seen from the preceding examples, not all cultural competency issues relate to foreign languages or cultures. Cultural competency encompasses gender, sexual orientation, socioeconomic status, faith, profession, tastes, disability, age, as well as race and ethnicity. Physicians should be sensitive to the unique needs of women in the communities they serve. Sensitivity to patients' reactions and possible behavioral differences will alert clinicians to ask appropriate questions and take appropriate actions. Using open-ended questions and active listening with patients is important.

Language and cultural barriers should be examined and addressed. Reaching out to community cultural leaders can be enormously beneficial in understanding cultural practices and accessing language services. For those who do not speak English, efforts should be made to provide assistance, such as offering appropriately trained interpreters and written translations of forms and patient education materials (5). In some circumstances, federal and state laws and regulations impose responsibilities on health care providers to accommodate individuals with limited English proficiency. Appropriate measures for overcoming communication barriers will depend on the circumstances of the individual practice and patient population. Various options may be available, including hiring bilingual staff for clerical or medical positions, using appropriate community resources, or using translation telephone services. Cosponsoring health fairs or information sessions in the local cultural community center can engender good relations with health care providers while being informative as well. Being known as the physician in the community who understands a particular culture can increase patient volume and the practice's net earnings. Reaching out to a particular segment of the community, such as gay and lesbian groups, and asking for information as well as offering to provide preventive medical talks can prove beneficial for the community and the practice (6). It is important to consider that not all situations require traditional allopathic solutions. Because patients interact with many individuals in the office and hospital, it is important to educate the front desk, billing, nursing, and ancillary medical staff in cultural sensitivity.

Resources and web sites can be found on the American College of Obstetricians and Gynecologists' web site at acog.org/goto/underserved.